Care Home: The Gables, Burnham-on-Sea

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What the care home does well The Gables provides care to a group of people of various ages and abilities. Staff demonstrated a good knowledge of individuals and their needs. Routines within the home are flexible to meet the different needs and abilities of people. Staff stated that the management in the home was open and approachable and that there were opportunities to voice their opinions. Some people living at the home are unable to fully express themselves verbally, people observed during the inspection appeared very relaxed with the people who supported them and there were varies activities for people to take part in. Care plans give comprehensive, up to date information about peoples` needs and preferred routines. Daily records show how people have been able to make choices about their day to day lives. There is a varied menu in place that encourages healthy eating and enables people to make choices. Specialist diets and preferences are catered for. Recruitment procedures are robust and all staff undertake a thorough induction programme and have access to ongoing training. The Gables, Burnham-on-Sea DS0000015983.V377316.R01.S.doc Version 5.2 Staff spoken with said it was a nice place to work and that everyone worked as a team to provide a good standard of care. What has improved since the last inspection? Since the last inspection some areas of the home have been redecorated and some carpets have been replaced. There are plans to install a wet room in one of the downstairs bathrooms and further decoration is planned. The kitchen has been refurbished and the lock has been removed to enable people living at the home to access it to make drinks and snacks. To seek the views of people about the menu at the home, taster sessions have been introduced. What the care home could do better: At this inspection errors in the recording of controlled drugs were noted and an immediate requirement was issued to ensure that all discrepancies were fully investigated. This was addressed within 24 hours of the inspection. Staff stated that training in the safe administration of medication was basic. It is therefore further required that the home ensures that all staff are made familiar with the procedures for administering and recording controlled drugs and their competency is assessed. Internal audits and visits by the registered provider had not identified the shortfall in the recording of medication. Neither had it been noted that one wardrobe was not secured and posed a risk of toppling forward possibly causing injury to someone living or working at the home. It is required that all quality assurance audits are more thorough to ensure that they identify shortfalls meaning that prompt action can be taken to correct. The house is an older style building and many areas require refurbishment and redecoration to ensure that it provides a comfortable and homely environment. Standards of cleanliness throughout the home were adequate but could be improved upon.The Gables, Burnham-on-SeaDS0000015983.V377316.R01.S.docVersion 5.2 Key inspection report CARE HOME ADULTS 18-65 The Gables, Burnham-on-Sea Grove Road Burnham-on-sea Somerset TA8 2HF Lead Inspector Jane Poole Key Unannounced Inspection 14Th October 09:45 The Gables, Burnham-on-Sea DS0000015983.V377316.R01.S.doc Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. The Gables, Burnham-on-Sea DS0000015983.V377316.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address The Gables, Burnham-on-Sea DS0000015983.V377316.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Gables, Burnham-on-Sea Address Grove Road Burnham-on-sea Somerset TA8 2HF 01278 782943 01278 782943 the.gables@craegmoor.co.uk 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) R J Homes Ltd Julie Hoskin Care Home 10 Category(ies) of Learning disability (10) registration, with number of places The Gables, Burnham-on-Sea DS0000015983.V377316.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To accommodate one named person over the age of 65, as stated in the letter from Craegmoor, dated 29th September 2004. 15th October 2008 Date of last inspection Brief Description of the Service: The Gables is registered with the Care Quality Commission (CQC) to accommodate up to ten people under the age of 65 who have a learning disability. (There is a condition on the homes registration that allows them to accommodate one named person over the age of 65). The home is a large detached property within walking distance of the sea front and all the amenities of Burnham on Sea. Accommodation is arranged over two floors and all bedrooms are for single occupancy. One room has en suite facilities and other people share communal washing and toilet facilities. The home has access to two vehicles for transport for people who use the service. The Registered Provider is R.J. Homes, which is owned by the Craegmoor Group Ltd. The registered Manager is Julie Hoskins. Fees at the home currently range from £787.00 to £1597.08 per week. Fees are dependant on the needs of the individual and consequent level of staff support required. Costs not included in the fees include, hairdressing, chiropody, personal items such as clothes and toiletries and peoples own birthday presents. The Gables, Burnham-on-Sea DS0000015983.V377316.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The focus of this inspection visit was to inspect relevant key standards under the Commissions Inspecting for Better Lives 2 framework. This focuses on outcomes for people and measures the quality of the service under four general headings. These are:- excellent, good, adequate and poor. This inspection was carried out over a one day period. During this time We, The Commission, were able to meet with people living and working at the home, tour the building, view records and observe care practices. We were given unrestricted access to all areas of the home and all records requested were made available. Before the inspection the registered manager completed an Annual Quality Assurance Assessment (AQAA) this gave information about the home and some indication of their plans for future improvement. What the service does well: The Gables provides care to a group of people of various ages and abilities. Staff demonstrated a good knowledge of individuals and their needs. Routines within the home are flexible to meet the different needs and abilities of people. Staff stated that the management in the home was open and approachable and that there were opportunities to voice their opinions. Some people living at the home are unable to fully express themselves verbally, people observed during the inspection appeared very relaxed with the people who supported them and there were varies activities for people to take part in. Care plans give comprehensive, up to date information about peoples’ needs and preferred routines. Daily records show how people have been able to make choices about their day to day lives. There is a varied menu in place that encourages healthy eating and enables people to make choices. Specialist diets and preferences are catered for. Recruitment procedures are robust and all staff undertake a thorough induction programme and have access to ongoing training. The Gables, Burnham-on-Sea DS0000015983.V377316.R01.S.doc Version 5.2 Page 6 Staff spoken with said it was a nice place to work and that everyone worked as a team to provide a good standard of care. What has improved since the last inspection? What they could do better: At this inspection errors in the recording of controlled drugs were noted and an immediate requirement was issued to ensure that all discrepancies were fully investigated. This was addressed within 24 hours of the inspection. Staff stated that training in the safe administration of medication was basic. It is therefore further required that the home ensures that all staff are made familiar with the procedures for administering and recording controlled drugs and their competency is assessed. Internal audits and visits by the registered provider had not identified the shortfall in the recording of medication. Neither had it been noted that one wardrobe was not secured and posed a risk of toppling forward possibly causing injury to someone living or working at the home. It is required that all quality assurance audits are more thorough to ensure that they identify shortfalls meaning that prompt action can be taken to correct. The house is an older style building and many areas require refurbishment and redecoration to ensure that it provides a comfortable and homely environment. Standards of cleanliness throughout the home were adequate but could be improved upon. The Gables, Burnham-on-Sea DS0000015983.V377316.R01.S.doc Version 5.2 Page 7 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. The Gables, Burnham-on-Sea DS0000015983.V377316.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, Burnham-on-Sea DS0000015983.V377316.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 2. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People wishing to move in receive comprehensive information about the home and have their needs assessed before a place is offered. EVIDENCE: The home has an up to date statement of purpose and service user guide. The service user guide is written in an easy read format with pictures making it more accessible to the people who live at The Gables. The service user guide sets out where additional costs may be incurred; for example for toiletries and personal clothing. No new people have moved into the home since the last inspection and there are currently no vacancies. There is however a full admission procedure which includes a full assessment of need and trial visits to the home for anyone wishing to move in. The Gables, Burnham-on-Sea DS0000015983.V377316.R01.S.doc Version 5.2 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans give comprehensive information about each person but are not user friendly documents. People are assisted to make choices about their day to day lives. EVIDENCE: Each person living at the home has a care plan which is personal to them. We looked at two care plans in detail. Both contained details about how staff should support people with personal care, communication, independence, finance and behaviour. Other care plans that were pertinent to the individual were also in place. Risk assessments had been completed for activities of daily life. It was noted that some care plans and risk assessments were statements of fact and not plans that could be monitored or evaluated. The Gables, Burnham-on-Sea DS0000015983.V377316.R01.S.doc Version 5.2 Page 11 The care plan files are large and not user friendly for people living at the home or staff. Important information is not always easy to find. The home is aware of this and is planning to put in place more user friendly plans that will place all important information about each person in smaller more accessible files. There was evidence that care plans were being regularly reviewed and all changes were documented. People are involved in the creation of their care plan in line with their abilities. One care plan seen had been partly written by the person living at the home. Daily records are written at the end of each shift, these record significant events, mood and dietary intake. They also indicate how people have made choices about the food that they eat and the activities that they have taken part in. The Gables, Burnham-on-Sea DS0000015983.V377316.R01.S.doc Version 5.2 Page 12 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): This is what people staying in this care home experience: 11, 12, 13, 14, 15, 16 & 17. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have access to a range of leisure activities at the home and in the community. People are encouraged to learn and develop independent living skills in line with their wishes and abilities. EVIDENCE: Any routines in the home are flexible to meet the different needs and preferences of the people who live there. People are able to spend time in communal areas or in the privacy of their rooms. People living at the home are encouraged to learn and develop independent living skills. People said that they were responsible for helping to keep their The Gables, Burnham-on-Sea DS0000015983.V377316.R01.S.doc Version 5.2 Page 13 bedrooms clean and tidy and for personal laundry. Some people assist with other household tasks. We observed people helping staff with lunch preparation and with table clearing. Since the last inspection the lock on the kitchen door has been removed to enable people to help themselves to drinks and snacks. Two people attend college courses and some other people attend day centres locally. The home also organises a wide range of activities for people to take part in. The home is within walking distance of the sea front and the town centre of Burnham on Sea. There are two vehicles that enable people to access amenities and facilities further away. People said that they went shopping, to local cafes and out for meals. There are various trips arranged in line with peoples’ interests. The AQAA states that ‘group trips are planned and chosen by residents who share the same interests.’ The day before the inspection some people had been out to Longleat for the day. Care plans seen contained photographs of people taking part in activities at the home and in the community. No one living at the home has voluntary or paid employment. There is a four week menu in the home and one person has devised their own menu. Many of the people who live at the home are unable to express themselves verbally. In order to seek peoples’ views on any new additions to the menu the home has recently held taster sessions. Staff stated that they encourage people to eat healthily and specialist diets are catered for. Lunchtime was observed, staff eat with people living at the home to support them and encourage a social atmosphere. The Gables, Burnham-on-Sea DS0000015983.V377316.R01.S.doc Version 5.2 Page 14 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 & 21. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive support with personal care in line with their abilities and wishes. Medication administration practices and recording need to improve to ensure that the system fully protects people living at the home. EVIDENCE: Care plans seen gave details of the level of support people require with personal care and the way that they like their support to be provided. The home cares for people of varying ages and abilities. Some people require full physical assistance whilst others need to be prompted. Staff spoken with had a good knowledge of individuals’ needs and preferences. All appointments with healthcare professionals outside the home are recorded. These showed that people have access to professionals in line with their The Gables, Burnham-on-Sea DS0000015983.V377316.R01.S.doc Version 5.2 Page 15 individual needs. Records seen included consultations with GPs, consultants, dentists and dieticians. One persons care plan contained evidence of regular weights which were being monitored and recorded at their request. Annual health checks and medication reviews are being carried out. Care plans contain details of what people would like to happen if they become very ill and after they die. These have been completed by the individual or by their representative. People with mobility difficulties have walking aids and there is a passenger lift to ensure that everyone has access to the first floor. Medication and Medication Administration Records (MARs) were viewed. There are appropriate storage facilities including storage for medication that requires refrigeration. Shortfalls were found in medication recording procedures and particular concerns around the recording of controlled drugs were highlighted. In one instance the figures recorded in the controlled drugs register did not add up correctly and when added correctly indicated that 7 tablets should be held on the premises but only 4 tablets were in the controlled drugs cupboard for this person. Two entries had been made in the controlled drugs register with no signatures. In one instance medication received into the home had not been recorded as received until 7 days after receipt. It had them been recorded on the Medication Administration Record (MAR) but the number recorded as received was incorrect. This was a medication that the homes’ policy states should be treated as a controlled drug but there was no entry in the controlled drugs register. An immediate requirement was issued for the registered person to carry out a full audit of medication and investigate the discrepancies found. The manager contacted the inspector on the night of inspection to state that this had been carried out and all medication had been accounted for. Medication Administration records were generally completed to a satisfactory level but hand written entries need to give more information. For Example one entry did not state how often a drug should be administered and did not state if there was a maximum dosage for a 24 hour period. Staff spoken with during the inspection stated that they received very basic training in the administration of medication. One person said that they had not found this sufficient to feel competent to administer medication. The Gables, Burnham-on-Sea DS0000015983.V377316.R01.S.doc Version 5.2 Page 16 The Gables, Burnham-on-Sea DS0000015983.V377316.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are policies and procedures in place to minimise the risks of abuse to people living at the home. EVIDENCE: The home has policies and procedures in respect of making a complaint, recognising and reporting abuse and whistle blowing. The AQAA states that everyone living at the home receives an easy read copy of the complaints procedure. The home has received two complaints since the last inspection; these have both been investigated and resolved. The manager gave evidence that they are familiar with the local safeguarding procedure and shares information appropriately with relevant people. Staff receive training in the protection of vulnerable adults and all asked were aware of the whistle blowing policy. It was observed that people living at the home were able to speak to the manager or other staff at any time. The Gables, Burnham-on-Sea DS0000015983.V377316.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28 & 30. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The Gables provides basic accommodation and many areas would benefit from redecoration and refurbishment. Standards of cleanliness throughout the home were adequate but could be improved upon. EVIDENCE: The Gables is a large older style building that provides accommodation over two floors. It is within walking distance of the sea front and other local facilities. The Gables, Burnham-on-Sea DS0000015983.V377316.R01.S.doc Version 5.2 Page 19 All bedrooms are for single occupancy and there are sufficient communal areas. Some bedrooms seen had been personalised. Since the last inspection some redecoration has taken place and some flooring has been replaced. A new kitchen has also been installed. Many areas of the home are in a poor state of décor and require up dating ensuring that they provide a comfortable homely environment for people. On the ground floor there is a large lounge area and dinning room, there is a second communal room on the first floor but this is not well used. There are plans to move the office upstairs to create more communal space on the ground floor. This was mentioned at the previous inspection but has still not been actioned. There is a garden to the front of the property and an enclosed courtyard at the rear. The use of the courtyard has been discussed at previous inspections but it has not been developed into a pleasant outside area for people who live at the home. There are communal bathrooms and toilets on both floors; these are serviceable but not homely or inviting. At the time of this inspection there was no cleaner and the home were in the process of recruiting. Care staff have been undertaking cleaning duties in addition to their care role. Standards of cleanliness throughout the home were adequate but could be improved upon. The Gables, Burnham-on-Sea DS0000015983.V377316.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the home are supported by an enthusiastic and knowledgeable staff team. Robust recruitment procedures minimise the risks of abuse to people who live at the home. EVIDENCE: The home employs 16 care staff, 10 (63 ) have a National Vocational Qualification (NVQ) in care at level 2 or above. (Figures taken from AQAA) The home has 5 care staff on duty between the hours of 8am and 8pm. The manager and deputy managers are in addition to this. Staff spoken with, felt that this was usually sufficient, but at times it would be beneficial to have more staff to enable more people to go out. Staff said that it was a nice place to The Gables, Burnham-on-Sea DS0000015983.V377316.R01.S.doc Version 5.2 Page 21 work and people worked as a team. Staff spoken with had a good knowledge of the people living at the home, and were enthusiastic about their jobs. There is an ongoing training programme for staff that includes a comprehensive induction. One member of staff said that they had had a “fantastic induction.” Ongoing training includes training in health and safety issues such as fire safety, moving and handling and first aid and training that is specific to the people living at the home including epilepsy, managing violence and aggression and methods of communication. Three recruitment records were seen during the inspection. They gave evidence of a robust recruitment procedure that minimises the risks of abuse to people living at the home. Written references are obtained for all new staff and everyone is checked against the Protection Of Vulnerable Adults (POVA) register before they begin work. Enhanced Criminal Records Bureau (CRB) checks are undertaken on all new staff. The Gables, Burnham-on-Sea DS0000015983.V377316.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 41 & 42 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The registered manager has the skills and experience to manage the home. Provider visits and audits need to be more thorough to ensure that shortfalls in all areas are identified and acted upon promptly. EVIDENCE: The registered manager is Julie Hoskin, she has the appropriate skills and experience to manage the home. In addition to the registered manager there is a deputy and a small group of senior carers. This means there is always a The Gables, Burnham-on-Sea DS0000015983.V377316.R01.S.doc Version 5.2 Page 23 senior member of staff on duty to offer support and guidance to less experience members of the care staff team. Prior to the inspection the manager completed an Annual Quality Assurance Assessment (AQAA.) This gave information about the home and some plans for future development and improvement. During the inspection the manager gave evidence of a commitment to ongoing improvements. Staff stated that the management team were open and approachable. It was observed that people appeared relaxed and comfortable with the homes’ manager. There are regular meetings for people living and working at the home. Staff said that meetings were an opportunity to share information and voice their opinions. A representative from the company that owns the home carries out regular visits and the outcomes of these visits are recorded as part of their quality monitoring. There are also in-house audits to monitor the quality of care and services offered. Although errors in the recording of controlled drugs went back several months none had been highlighted in any audits or visits carried out. There is a computerized system in place to ensure that people have access to their personal money. Records of personal accounts were seen but no personal monies are held at the home. Receipts are retained for all personal expenditure. A maintenance person is employed who carries out day to day maintenance within the building. Equipment in the home is regularly tested and serviced by outside contractors. There are safety certificates in place for the electricity and gas installations and portable electrical appliances are tested on an annual basis. The manager stated that the home had recently been inspected by the local fire officer who was happy with the equipment and procedures in place. During a tour of the building it was noted that one wardrobe had not been secured and posed a danger of toppling forward causing injury to someone living or working at the home. This was rectified before the end of the inspection. Up to date certificates of registration and insurance are displayed. The Gables, Burnham-on-Sea DS0000015983.V377316.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 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 x 26 2 27 1 28 2 29 x 30 2 STAFFING Standard No Score 31 x 32 2 33 3 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 3 x LIFESTYLES Standard No Score 11 3 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 1 2 2 3 2 x 2 3 x Version 5.2 Page 25 The Gables, Burnham-on-Sea DS0000015983.V377316.R01.S.doc no 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 YA20 Regulation 13(2) Requirement Within 24 hours of the inspection the registered person must carry out a full medication audit and investigate the discrepancies between controlled drug records and stocks held on the premises. A system must then be put in place to ensure that all staff are familiar with the procedures for recording and dispensing controlled drugs. Competency of staff should be assessed and recorded. IMMEDIATE REQUIREMENT ISSUED 2 YA24 23 (b) The registered person must 31/12/09 ensure that the home is kept in a good state of repair internally and externally. Quality monitoring and audit 31/12/09 systems must be more thorough to ensure that any shortfalls are identified and acted upon promptly. Timescale for action 15/10/09 3 YA39 13 (4) The Gables, Burnham-on-Sea DS0000015983.V377316.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard YA6 YA28 YA30 Good Practice Recommendations The registered manager should ensure that care plans are more user-friendly for people living at the home and staff. The courtyard area should be upgraded to provide a pleasant outside space for people living at the home. The registered person should review the cleaning at the home to ensure that cleanliness is always maintained to a good standard. The Gables, Burnham-on-Sea DS0000015983.V377316.R01.S.doc Version 5.2 Page 27 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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